PARTICIPANT REGISTRATION FORM EMERGENCY MEDICAL INFORMATION AWARENESS OF RISK AND RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT In the event a serious medical emergency occurs, care will be provided by the nearest local medical facility Please provide us with the following information as well as any additional information that would be appropriate for medical professionals to know in the event of an emergency REGISTRATION INFORMATION: (Please print clearly) Participant Full Name: _ Congregation Name: _ City: EMERGENCY and MEDICAL INFORMATION: Emergency Contact: _ Relationship: _ Telephone Number: Alternate Telephone Number: _ Allergies (Food or Drug): Other useful medical information: _ I herby consent to allow my child to participate in the Homelessness Awareness SleepOut event offered by Gustavus Adolphus College from November 13-14, 2015 I understand that my child can get hurt anytime they are involved in physical activity or in case of inclement weather In consideration for this participation, I agree to waive any cause of action or claim that I/we may have, accrue, obtain, or be entitled, against Gustavus Adolphus College (Gustavus), or their agents, arising out of participation in this event I, for myself, further agree to indemnify and hold Gustavus, and their agents harmless for any injury or harm to my child arising out of participation in this event I FURTHER AUTHORIZE THE EVENT COORDINATOR TO ARANGE FOR TRANSPORTATION AND IMMEDIATE MEDICAL CARE IN THE EVENT OF AN EMERGENCY _ (Signature of Parent/Guardian) Date: _